Network meta-analysis comparing blood cardioplegia, Del Nido cardioplegia and custodiol cardioplegia in minimally invasive cardiac surgery.

INTRODUCTION: Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise the cardiopulmonary bypass and cross clamp time. However, the best cardioplegia for myocardial protection in adult minimally invasive cardiac surgery remains controversial. We aimed to conduct a meta-analysis to analyse the current evidence in the literature. METHOD: A systematic review and meta-analysis was performed following the updated 2020 PRISMA guideline. Articles published in the five major electronic databases up 1st of April 2021 were identified and reviewed. The primary outcome was in-hospital or 30-day mortality. Traditional pairwise and Bayesian network meta-analyses were conducted. RESULTS: Nine articles were included in this study. The use of Del Nido cardioplegia was associated with a lower volume of cardioplegia used (Del Nido vs Blood, 1105.62 mL+/-123.47 vs 2569.46 mL+/-1515.52, p<0.001), cardiopulmonary bypass (Del Nido vs Custoidol vs Blood: 91.67+/-14.78 vs 138.05 +/- 21.30 vs 119.38+/-26.91 minutes, p<0.001) and cross-clamp time (Del Nido vs Custoidol vs Blood: 74.99+/-18.55 vs 82.01 +/- 17.28 vs 93.66+/-8.88 minutes, p < 0.001). No differences were observed in the incidence of in-hospital/30-day mortality rate, new onset of atrial fibrillation and stroke. Ranking analysis showed the Custoidol solution has the highest probability to be the first ranked cardioplegia. CONCLUSION: No differences were found between blood and crystalloid cardioplegia in adult minimally invasive cardiac surgery in several clinical outcomes. The cardioplegia of choice in minimally invasive cardiac surgery remains the surgeons' decision and preference.

Propensity matched analysis of minimally invasive versus conventional isolated aortic valve replacement.

OBJECTIVE: To analyse the early and mid-term outcome of patients undergoing conventional aortic valve replacement (AVR) versus minimally invasive via hemi-sternotomy aortic valve replacement (MIAVR). METHODS: A single centre retrospective study involving 653 patients who underwent isolated aortic valve replacement (AVR) either via conventional AVR (n = 516) or MIAVR (n = 137) between August 2015 and March 2020. Using pre-operative characteristics, patients were propensity matched (PM) to produce 114 matched pairs. Assessment of peri-operative outcomes, early and mid-term survival and echocardiographic parameters was performed. RESULTS: The mean age of the PM conventional AVR group was 71.5 (±8.9) years and the number of male (n = 57) and female (n = 57) patients were equal. PM MIAVR group mean age was 71.1 (±9.5) years, and 47% of patients were female (n = 54) and 53% male (n = 60). Median follow-up for PM conventional AVR and MIAVR patients was 3.4 years (minimum 0, maximum 4.8 years) and 3.4 years (minimum 0, maximum 4.8 years), respectively. Larger sized aortic valve prostheses were inserted in the MIAVR group (median 23, IQR = 4) versus conventional AVR group (median 21, IQR = 2; p = 0.02, SMD = 0.34). Cardiopulmonary bypass (CPB) time was longer with MIAVR (94.4 ± 19.5 minutes) compared to conventional AVR (83.1 ± 33.3; p = 0.0001, SMD = 0.41). Aortic cross-clamp (AoX) time was also longer in MIAVR (71.6 ± 16.5 minutes) compared to conventional AVR (65.0 ± 52.8; p = 0.0001, SMD = 0.17). There were no differences in the early post-operative complications and mortality between the two groups. Follow-up echocardiographic data showed significant difference in mean aortic valve gradients between conventional AVR and MIAVR groups (17.3 ± 8.2 mmHg vs 13.0 ± 5.1 mmHg, respectively; p = 0.01, SMD = -0.65). There was no significant difference between conventional AVR and MIAVR in mid-term survival at 3 years (88.6% vs 92.1%; log-rank test p = 0.31). CONCLUSION: Despite the longer CPB and AoX times in the MIAVR group, there was no significant difference in early complications, mortality and mid-term survival between MIAVR and conventional AVR.

Understanding aortic valve repair through Ozaki procedure: A review of literature evidence.

BACKGROUND: Aortic valve neocuspidization (AV Neo) using glutaraldehyde-treated autologous pericardium was first reported by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve in selected patients as long-term anticoagulation is not required and shows promising midterm results and durability. METHOD: A comprehensive search was performed on the major database using the search terms "Ozaki technique" AND "Aortic Valve Neocuspidization" AND "AV Neocuspidization" AND "Autologous pericardium" AND "glutaraldehyde-treated autologous pericardium." Articles up to August 1st, 2021 were included in this study. RESULTS: A total of nine studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve (AV) and 31.37% of patients' native AV was bicuspid. Three studies reported their experience performing AV Neo via ministernotomy. CONCLUSION: AV Neo can be a suitable alternative to surgical AV replacement in selected patients. The short- and midterm outcomes are comparable without the need for long-term oral anticoagulation. Long-term follow-up data are required for this novel approach to be widely adopted.

Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: a network meta-analysis.

BACKGROUND: Patient blood management (PBM) interventions aim to improve clinical outcomes by reducing bleeding and transfusion. We assessed whether existing evidence supports the routine use of combinations of these interventions during and after major surgery. METHODS: Five systematic reviews and a National Institute of Health and Care Excellence health economic review of trials of common PBM interventions enrolling participants of any age undergoing surgery were updated. The last search was on June 1, 2019. Studies in trauma, burns, gastrointestinal haemorrhage, gynaecology, dentistry, or critical care were excluded. The co-primary outcomes were: risk of receiving red cell transfusion and 30-day or hospital all-cause mortality. Treatment effects were estimated using random-effects models and risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity assessments used I2. Network meta-analyses used a frequentist approach. The protocol was registered prospectively (PROSPERO CRD42018085730). RESULTS: Searches identified 393 eligible randomised controlled trials enrolling 54 917 participants. PBM interventions resulted in a reduction in exposure to red cell transfusion (RR=0.60; 95% CI 0.57, 0.63; I2=77%), but had no statistically significant treatment effect on 30-day or hospital mortality (RR=0.93; 95% CI 0.81, 1.07; I2=0%). Treatment effects were consistent across multiple secondary outcomes, sub-groups and sensitivity analyses that considered clinical setting, type of intervention, and trial quality. Network meta-analysis did not demonstrate additive benefits from the use of multiple interventions. No trial demonstrated that PBM was cost-effective. CONCLUSIONS: In randomised trials, PBM interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery.

Subxiphoid incisional hernias post median sternotomy: A literature review.

BACKGROUND: Subxiphoid incisional hernias are one of the complications following a median sternotomy, a surgical procedure to provide access to the mediastinum. Incidence has been reported between 1% and 4%, although the true incidence is not well known due to its asymptomatic nature. METHOD: A comprehensive search was performed on multiple sites. Keywords included "incisional hernia OR Subxiphoid hernia" AND "Median sternotomy OR Cardiac Surgery OR Coronary artery bypass graft OR Transplant OR Valve replacement". Articles up to August 1, 2020, were included in this study. RESULTS: Eight articles were included in the study, with a total number of 132 patients identified. The incidence ranged from 0.81% to 3.44%. There was a mixture of repair methods and follow-up period reported. Recurrence post repair ranged from 10% to 43%. CONCLUSION: Subxiphoid incisional hernias remain challenging to manage. We have discussed the incidence, risk factors, preventions, and management of subxiphoid incisional hernias including both the open and laparoscopic techniques.

Top 100 cited manuscripts in aortic valve replacement: A bibliometric analysis.

This bibliometric analysis aims to identify publications and highlight the key areas that have shaped modern clinical practices for aortic valve replacement (AVR). In this paper, the top 100 most cited manuscripts for AVR are analyzed. The Thomson Reuters Web of Science database was searched using the terms "aortic valve replacement," "AVR," "sAVR," "tAVR," or "TAVI." The results were ranked by citation number and the top 100 articles were further analyzed by evaluating the subject, author, journal, year of publication, institution, and country of origin. Thirty-thousand and eight hundred eligible papers were examined, with an accumulation of 81 851 citations in total and a mean citation of 819 per manuscript (ranged: 344-4180). The New England Journal of Medicine had the most manuscripts whereas Circulation had the most citations. The number of citations has also significantly increased for articles published after 2000.The most cited manuscript highlighting the management of valvular heart disease, was written by Baumgartner et al By providing the most influential references, this work serves as a comprehensive guide to topics of interest in the field of AVR.

Fourteen years of litigation claims in cardiothoracic surgery in the United Kingdom National Health Service.

Approximately 36 400 cardiac and 23 100 thoracic operations are carried out in the United Kingdom between 2006 and 2015. National Health Service (NHS) resolution, as known as the NHS litigation authority, is one of the essential bodies of the Department of Health. Its purpose is to provide NHS expertise to resolve concerns fair and square share learning for improvement. We aim to evaluate and increase awareness of medicolegal cases in cardiothoracic surgery. Total numbers and details of claims coded by NHS resolution in cardiothoracic surgery from 2004 to 2017 were requested under the Freedom of Information Act 2000. The data provided in successful claims is further breakdown into damages paid to the claimant, defence cost, claimant cost paid and the sum of the three. In contrast, unsuccessful claims only include the defence cost. Moreover, data provided also includes further analysis of primary causes and primary injuries for Claims Closed/Settled with damages paid. There were 753 claims recorded from 2004 to 2017, of which 415 (55.11%) were successful. The number of claims has been steadily increasing since 2004, with two significant raises from 2009/10 to 2010/11 (37-55, 48.64% raise) and 2012/13 to 2013/14 (49-69, 40.82% raise). The mean successful claim ratio was 69.58% (range, 47.56%- 83.33%) There is also a steady increase in the successful ratio from 2004 to 2017. In summary, this is the first study published in relation to litigation claims on cardiothoracic surgery in the United Kingdom. The results have provided insight on claims made against cardiothoracic surgery.

Is there a national variation in cardiothoracic trainees' satisfaction? Evaluation of the United Kingdom General Medical Council national training surveys.

BACKGROUND: The national training surveys was first started in 2006, with an aim to determine the quality of the national training standard. All trainees working in a General Medical Council approved training post are required to complete the survey. We aimed to evaluate cardiothoracic trainees' satisfaction and determine whether there is variation in the United Kingdom. METHOD: The national training survey report in cardiothoracic surgery from 2012 to 2019 was obtained from the General Medical Council website. The cardiothoracic centers were divided based on their geographic locations. Comparisons in all 18 indicators in the national training surveys report were made between the four counties (national) and four local education training boards (LETBs) in England (Regional). Centers with less than 4 years of data were excluded from this study. RESULTS: Thirty-three cardiothoracic centers are included in this study The top three areas that trainees are most satisfied are clinical supervision (out of hours) (91.65), clinical supervision (90.65), and educational supervision (88.27). On the other hand, trainees are less satisfying with the handover (62.63), rota design (61.91), and workload (45.07). It is worth noting that workload is the only area of less than 60%. In addition, there is no national variation in all 18 indicators CONCLUSION: Our data suggested that there is no difference in overall trainee satisfaction in the United Kingdom. However, there are differences in various indicators between England and the three other nations. Individual hospital should reflect on trainees' evaluation on the national training surveys report and improve on specific areas if deemed unsatisfactory.

Proximal arterial cannulation in thoracic aortic surgery-Literature review.

Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques.

Early Exposure and Its Impact on Cardiothoracic Surgery: an Experience of Medical Education in The United Kingdom.

INTRODUCTION: Cardiothoracic surgery (CTS) has seen a decline in interest and application rates in recent years. As a relatively small speciality, teaching and placements in CTS are often not included during undergraduate study and postgraduate training. We aim to evaluate the exposure to CTS during both undergraduate study and postgraduate training. METHODS: A ten-question online survey was designed and delivered to Foundation Year Two (FY2) doctors who graduated in 2017 and completed their two-year postgraduate foundation training in 2019. Medical schools with no graduates in 2017 and 2018 were excluded from our study. IBM® SPSS Statistics, version 25, and Microsoft Excel 365® were used for Student's t-test statistical analysis. RESULTS: Three hundred and six FY2 doctors across 16 medical schools completed the survey, none of which included compulsory CTS attachments as their undergraduate curriculum. Thirty-two respondents (10.5%) underwent CTS attachments lasting between one to three weeks. Only 14 (43.8%) had worked in a cardiothoracic unit during their two-year Foundation Programme; 10 of which (71.2%) subsequently made an application for cardiothoracic speciality training. Most of the participants with previous exposure to CTS, during either undergraduate study or postgraduate Foundation Programme training or both, were significantly more likely to make an application to CTS training (P<0.05). CONCLUSION: Our study suggests that doctors with increased exposure to CTS during undergraduate study and postgraduate training are more likely to pursue a career in CTS. Targeted interventions at both stages may improve interests in CTS and the number of prospective applicants.

Current status and problems of orthopaedic residents in Thailand and Myanmar.

Background: There is no research about current experiences of orthopaedic residents in Thailand and Myanmar. Methods: A questionnaire survey was distributed among Thai and Myanmar orthopaedic residents to assess their current experiences. This study included a total of 168 participants, comprising 92 orthopaedic residents in Thailand, and 76 in Myanmar who answered the questionnaire. The survey comprised nine questions about issues such as the contents of residency training programs, current training satisfaction, and future careers. The survey was administered anonymously between October 2020 and January 2021. Results: Regarding training content, 24 residents (14.3%) reported being "very satisfied", 103  (61.3%) were "satisfied", 37 (22.0%) were "moderately satisfied", and four (2.4%) were "dissatisfied", and respondents spent a mean of 3.1 h/day reading textbooks and research papers. As for salary, five (3.0%) residents answered "satisfied", 46 (27.4%) responded "moderately satisfied", and 117 (69.6%) were "dissatisfied". Conclusions: Many orthopedic residents in Thailand and Myanmar were enthusiastic about and satisfied with their training. Their only problem was that the salary was low.

Reinterventions and new aortic events after aortic surgery in Marfan syndrome.

OBJECTIVES: Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation. METHODS: Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998-2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed. RESULTS: One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients. CONCLUSIONS: After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

Techniques and approaches for revascularisation of left heart coronary diseases.

Coronary artery disease and its associated clinical sequelae are a significant medical burden to clinicians and patients. Severe coronary artery disease presenting in the context of acute myocardial ischaemia, or stable plaques causing chronic symptoms despite best conservative and pharmacological intervention, are often amenable to further intervention such as coronary artery bypass grafting. This procedure has been extensively compared to newer and less invasive techniques, such as percutaneous coronary intervention, and other minimally invasive procedures such as robotic or endoscopic techniques. This review summarises the current evidence on revascularisation of the left coronary artery system, with particular emphasis on key clinical endpoints of mortality, myocardial infarction, stroke and repeat revascularisation.

COVID-19 and literature evidence: should we publish anything and everything?

COVID-19 first presented in Wuhan, Hubei Province, China in December 2019. Since then, it has rapidly spread across the world, and is now formally considered a pandemic. As of 4th of May more than 3.2 million people have been infected and over 250,000 people has died. Since the very start, scientists and researchers have tried to utilize this case to publish academic experiences and suggestions toward fighting this virus, which is lethal in some cases. To date, more than 9,000 academic papers have been published since December 2019. The quality of publications varies from a plane letter to editor to randomized studies. This review aims to analyse the current published literature related to COVID-19 and assess the quality of such articles.

Antimicrobials use and resistance on integrated poultry-fish farming systems in the Ayeyarwady Delta of Myanmar.

Antimicrobials are used to support livestock health and productivity, but might pose a risk for the development of antimicrobial resistance; in particular, when multiple livestock species are raised together in production systems. On integrated chicken-fish farms, chickens are raised over fish ponds and poultry faeces is excreted into the ponds. We investigated antimicrobial usage and the antimicrobial susceptibility of Escherichia coli cultured from poultry faeces on 301 integrated farms in Ayeyarwady Delta of Myanmar. Antimicrobials were used by 92.4% of farmers for chickens, but they were not applied to fish. The most common antimicrobials used were Octamix (amoxicillin and colistin sulfate) on 28.4%, enrofloxacin on 21.0% and amoxicillin on 16% of farms. Overall, 83.1% (152/183) of the E. coli were resistant to at least one antimicrobial. The highest level of resistance was to amoxicillin (54.6%), tetracycline (39.9%), sulfamethoxazole/trimethoprim (35.5%) and enrofloxacin (34.4%). Multidrug resistance was identified in 42.4% of isolates. In general, we found similar levels of antimicrobial resistance in non-users of antimicrobials as in users of antimicrobials for more commonly applied antimicrobials. Overall, antimicrobial resistance was lower in chickens on these integrated farms in Myanmar, compared to poultry farms in other countries of South East and East Asia.

Early Exposure and Its Impact on Cardiothoracic Surgery: an Experience of Medical Education in The United Kingdom

ABSTRACT Introduction: Cardiothoracic surgery (CTS) has seen a decline in interest and application rates in recent years. As a relatively small speciality, teaching and placements in CTS are often not included during undergraduate study and postgraduate training. We aim to evaluate the exposure to CTS during both undergraduate study and postgraduate training. Methods: A ten-question online survey was designed and delivered to Foundation Year Two (FY2) doctors who graduated in 2017 and completed their two-year postgraduate foundation training in 2019. Medical schools with no graduates in 2017 and 2018 were excluded from our study. IBM® SPSS Statistics, version 25, and Microsoft Excel 365® were used for Student's t-test statistical analysis. Results: Three hundred and six FY2 doctors across 16 medical schools completed the survey, none of which included compulsory CTS attachments as their undergraduate curriculum. Thirty-two respondents (10.5%) underwent CTS attachments lasting between one to three weeks. Only 14 (43.8%) had worked in a cardiothoracic unit during their two-year Foundation Programme; 10 of which (71.2%) subsequently made an application for cardiothoracic speciality training. Most of the participants with previous exposure to CTS, during either undergraduate study or postgraduate Foundation Programme training or both, were significantly more likely to make an application to CTS training (P<0.05). Conclusion: Our study suggests that doctors with increased exposure to CTS during undergraduate study and postgraduate training are more likely to pursue a career in CTS. Targeted interventions at both stages may improve interests in CTS and the number of prospective applicants.